Power Shift

Jim Bradley has a mission to bring electronic commerce to the physician, a great need he saw as CIO at United HealthCare in Minneapolis. From his vantage point in one of the country’s most progressive cities for managed care, Bradley witnessed the onset of healthcare reform and the explosion of change in healthcare financing. At the same time, the Internet and Internet technologies emerged with much fanfare, and with them, the potential--in his view--to dramatically alter the way physicians practice medicine.

He had a challenging job with a rapidly growing managed care giant, an outstanding IS team, an industry he loved--yet he realized that providing powerful electronic tools to physicians was out of his reach working on the managed care side of the fence. So in 1995, he left United HealthCare to search for the answer, and one year ago, formed his own company, Abaton.com. A believer in Internet and object-oriented technologies as the foundation for point-of-care, clinical information and connectivity, Bradley’s goal is to render a means for physicians to work from any location. He talks with Healthcare Informaticsabout the tidal wave of change enabling an overhaul of the way physicians work.

What made you leave a secure position and enter the risky world of software development?What took me from United into the entrepreneurial world was really a fundamental shift that I saw happening with United’s efforts, particularly in the company’s merger with Metra Health. I felt that we weren’t going to be able to pay attention to what I saw was a growing need to address physicians at the point that decisions are being made in healthcare delivery. We felt that physicians ought to have automated tools to keep track of patient information so they could order the use of resources, if there was an intervention or alert that should occur at the point of the ordering process as opposed to after the fact. We believe we’re creating the tool set that allows a physician to automate this workflow process. The net result is he or she will practice smarter, more consistent medicine.

What is the potential for start-ups of physician automation?We’re at the vortex of two revolutions. Physicians are under pressure like they never have been before, and are being recognized as key influencers. At the same time along comes all this new technology that solves so many issues that have been burdening practitioners. The time from the market and technology point of view is right. The question then becomes, is it crowded space out there?

We hear that five percent of physicians use an electronic medical record--we actually think it’s less than that. It represents a broad opportunity.

How is technology changing the way physicians work?Physicians are feeling the need to make more informed clinical decisions, and to become more efficient. With more risk being shared with physician organizations, these better- informed decisions add up to better financial success. For payors as well, collaborating at the point of care provides a foundation for far superior medical management. It also moves medical management from a retrospective policing to a prospective collaboration.

How much of an impact will the Internet have on the business of healthcare?Internet technology is founded on certain technical protocols for electronic communications. Those protocols today dominate most corporate and governmental networks, and they’re here to stay. The platform that we’re developing on is very tried and true. Now, how quickly will we, for example, make patient records available to a physician over the pure public Internet connection--I think we can debate that. Part of that will be how quickly people are comfortable with the tools that secure such information, how quickly we can manage the performance of that connection… there are any number of questions that still remain. It is inevitable that physicians are going to use these technologies to get the information they will need to make decisions. I think the world never goes back to the way it was.

One of the primary changes will be a shift in power. Today the payor, through contracts and retrospective tools, tends to try and manage reimbursement--to a certain extent, not well. This year most of the large payors have had major earnings surprises or disappointments. I think what you’ll see is risk-sharing with physicians. This technology enables a shift of power to those organizations that know physicians, or in some cases have physicians working for them, that are focused on the process of care delivery. When the thing settles down, the power will have shifted back to the physician.

Are performance, reliability, security and privacy true barriers to using the Internet?Some of the concerns with the Internet today are justified. That’s not to say you can’t manage around them. Let’s take, for example, performance. If the typical experience of logging onto an ISP is you get a busy signal, and once you do get through you get a poor quality line and your modem is not even 28.8, and then you ask for a download of an MRI--I think I’ve just given you a recipe for absolute disaster. So I think you do have to use some common sense.

We have to pay attention to performance at the point of care. We’ve got to be getting near a second to display information. The only exception we can see to that is a physician on call, at home, it’s two o’clock in the morning and he wants to look at a scan, and he’s willing to wait 120 seconds to look at it rather than driving to the hospital.

Privacy and security is a far more gritty issue. I am convinced there are some incredibly smart people in the world who will break into networks for fun. The potential to help patient care and quality, to control costs, to rationalize an industry that really is a cottage industry, and doing it in the right way by giving control over the transaction back to the physician… the benefits of that so outweigh the risk that I think it’s absolutely the right thing to do--as long as we are prudent in safeguarding the information.

To say that there’s no way we’ll ever let a breach occur is foolhardy. It will happen. I hope we can keep it in perspective when it does happen, so it doesn’t set the industry back. If we don’t, we’ll allow paranoia to prevent us from coordinating care, collecting data to understand how care is being delivered… all the positive benefits of the activity. In the meantime, if a breach occurs here, our company is out of business, all the hard work is over. So we have to take that very seriously.

Authentication is another important consideration. If you’re dealing with a clinical transaction like prescribing a drug, you have to make sure that the person on the other end of the line is an authorized party. It’s important that someone take the role of the trust authority and legitimize physician access. Ultimately there should be a higher authority--just like doctors have a DEA number. They need to have their own private and public keys so they can both access and send information and sign orders in a way that we’re very comfortable that they were the ones who signed it.

Which is tougher, the technical or human aspects of security?A lot of it is a human problem. The greatest security problems today come from the lack of use or incompetent use of tools that are available. For example, you install a new operating system on one of your servers and the server comes with an administrator account with the password of "admin," and you never change it, and it has full rights to everything on the system. Well that’s just inviting disaster. You know that a lot of organizations haven’t done a prudent job of just doing the basics.

I’m seeing a faster and faster adoption of Internet technologies, and more and more physicians at the table wanting to learn how to use these technologies. Various blips in history could upset that pace of change. One of them could be a very material and visible security breach associated with a major healthcare organization. Imagine someone getting into a database someplace, clearing for HIV positive patients and publishing it on the Internet. That kind of thing would be absolutely devastating.

Having said that, Internet technology allows us to do peer-to-peer networking, and the cost of bandwidth continues to come down. The Abaton.com offering, in a community where we are doing business, is basically a private network.

The advantage of the public Internet, however, is--let’s say I want to do business with a physician in rural Minnesota. I’ll never be able to cost justify the network deployment of the private network there, where the Internet tears that barrier down. It really lowers the cost of networking.

I think what you’ll see is for high volume use and very sensitive use, private networks will still be the technology du jour. You’ll start to see in rural medicine and elsewhere some Internet transactions coming along.

What do you think about ’push’ technology in healthcare?One of the people we were talking to about strategy is a psychiatrist and a physician. We were talking to him about the appropriateness of sharing information. His comment was, I want to know if one of my patients was in the hospital over the weekend for a cardiogram, because it may be something physical and it may not be, and I want to know about the general well-being of my patient. He wanted to "subscribe" to the patient. Any transaction that happens with a patient he wants to have a message pushed to him. When a lab result comes back that’s out of bounds, or when a mammogram comes back with indications of a problem, you can move them to the highest priority and push them to the attending physician in a way that he actually sees them.

What will be the most significant effects of the Internet’s entry into adulthood?On access, bandwidth and technology keep getting cheaper. More traffic is sharing and hopefully effectively using that bandwidth, so in some ways, I see pure capacity getting cheaper. With the explosion in demand, however, we will see business use coming at a pricing rate exceeding the base AOL rate. For that increase, business users can expect better performance management, heightened security and so on.

What about government regulation?HCFA and the government in general are going to be involved. I am following some of their current thoughts on the Internet, which seem a bit overreaching. For example, a recent memorandum forbidding the use of the Internet for healthcare transactions came out of the blue and appeared not well thought out. At the same time, Al Gore, in particular, is a major proponent of the information highway, and I can’t think of a better industry to improve through its use.

Will business, including healthcare, get back their investment in Web technologies?I think a couple of things are going to happen. Companies will demand a return on their networking investment. We’ve all heard the predictions that the Internet is going to collapse under its own weight. What that means is more parties will bring bandwidth to the environment, some of which will have a profit motivation. Therefore at some point we’ll pay more for access.

The return is very much there when you consider both the administrative efficiencies for conducting business within the healthcare framework, and the potential savings of appropriate management of the conduct of that business. Without clinical connectivity, outcomes are nothing but a pipe dream.

From Rx to HMOs to Software

Jim Bradley’s 15-some years in healthcare have done little to taint his enthusiasm for the field: "I immediately loved the business, a love that has never left me. There is no industry in which information matters more, and if you’re in an information-based profession, I feel your career is well-served by picking an industry where the company’s survival itself depends upon how you do your job."

A statistics and programming background and an MBA in finance led him to IS jobs at pharmaceutical company Pfizer in St. Louis and Chicago; HMO management company American Medcenters and Partners National Health Plans (now Aetna U.S. Healthcare), Minneapolis/St.Paul; managed care consulting at Price Waterhouse; and then to the chief IS position at United HealthCare (UHC) in 1989.

When Bradley joined UHC, it was a $400 million company; by the time he left in 1995, after a period of remarkable consolidation in the market, it had grown to $4 billion. "It was a very formative time in the Minneapolis/St. Paul marketplace where managed care trends were just exploding," Bradley says. "Along with this, all of the adversarial relationships came with that level of change--severe dysfunction in relationships between the physicians and the managed care organizations and the hospitals."

Even though Bradley calls his years at UHC an "absolute privilege" in which he built a nationally recognized information systems team that was the envy of his peers, he was motivated to venture into the commercial software world, first with Health Systems Integration Inc., a Compucare division based in the Minneapolis suburb of Bloomington, and then finally branching off to form his own company, Abaton.com.

Through the help of two San Francisco venture capitalist firms, the company was launched on January 1, 1997. Abaton.com is now rolling out its initial offerings: modules for connectivity to pharmacies, pharmacy benefit management companies and laboratories; and the "Pretty Good Medical Record." Abaton.com has four customers under contract or in negotiations in Minneapolis/St. Paul and Louisville, Ky.

Polly Schneider is senior editor at Healthcare Informatics.

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